We definitely have the personnel, tools, and resources to achieve our goals. Once the diagnosis of diabetes is established, we must provide a diabetic meal plan to achieve or approach desirable body weight. The rule of thumb to determine ideal body weight depends on the sex, height body frame, weight, and daily physical activity of the individual. A fivefeet- tall man should weigh 106 pounds; add six pounds for each additional inch. A five-feet-tall woman should weigh 100 pounds; add five pounds for each additional inch. Ten percent of ideal weight can be added or subtracted for a large or small body frame. Additional calories are estimated for increased exercise or physical activity at work or play. To maintain ideal body weight, prescribe 12 calories per pound. For weight reduction, prescribe 10 calories per pound of ideal body weight and for weight gain prescribe 15-20 calories per pound. A reduction of 500 calories per day (3,500 calories per week) will decrease body weight by one pound per week. Your office scale will determine the patient’s adherence to your weight loss or gain prescription.

Table 1: Risk of Associated Disease According to Body Mass Index and Waist Size

First, a copy of your, or the diabetes educator’s or dietician’s, diabetic meal plan must be explained to the patient and family member or significant other. The importance of body weight, body mass index, and waist circumference needs to be emphasized to the patient (see Table 1).

The second step is an exercise program to help with weight reduction or weight maintenance. Additional benefits include lower blood glucose and triglycerides, improved endothelial function, and decreased inflammation and blood viscosity. A major advantage of exercise is an improved sense of wellbeing and confidence and can include walking, bike riding, swimming, running, or an exercise of the patient’s choice. It is best to exercise at the same time daily, at least five times per week.

The third step is self-monitoring of blood glucose. Current meters measure whole blood and convert the value to plasma glucose. In the early stages of glucose self-monitoring, the whole-blood A1c was an average of 6% or an average of 120mg/dl. The plasma glucose value A1c of 6% is an average of 136mg/dl. Since we strive to achieve a fasting plasma glucose of 110mg/dl, it is clear we need to set an A1c goal of <6%.

I recommend obtaining blood sugars before each meal and before bedtime. Occasionally, an early-morning glucose measurement is obtained if hypoglycemia is suspected or when using an insulin protocol, insulin pump, or inhaled insulin. If the patient is in hospital or a nursing home, the blood glucose should be obtained when the meal tray enters the room and not at a fixed time schedule. The obtained glucose results should be plotted on a graph by the patient and the results evaluated by the patient, physician, and/or diabetes educator. The graphing and analysis of the blood glucose pattern will help in identifying the high peaks and avoid low blood glucose. An adjustment in the meal plan, meal scheduling, physical activity, or medication will help solve the problem and improve blood glucose control. Once control is improved, blood glucose testing can be gradually reduced to twice daily. Monitoring can be before breakfast and evening meals and some days before lunch and before bedtime.